Form 207 Hcc - Health Care Center Tax Return - 2010
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1Form 207 HCC
2010
Department of Revenue Services
State of Connecticut
PO Box 2990
Health Care Center Tax Return
Hartford CT 06104-2990
(Rev. 12/10)
Complete this return in blue or black ink only.
General Information
D. If this is a fi nal return, is the insurance company:
A.
Check if this is an amended return.
No longer licensed in Connecticut; out of business
B. Change of:
Address
Merged/reorganized _______________________
Domicile, enter new domicile: ___________________
Enter survivor’s CT Tax Registration No.
E. The insurance company is currently in:
C. If this is a short period,
Receivership
Rehabilitation
enter period covered by this return: __________________________
Name of company
Connecticut Tax Registration Number
Taxpayer
Address
Number and street
PO Box
Date received (DRS use only)
Please
type
or print.
City or town
State
ZIP code
Federal Employer ID Number (FEIN)
1 Total net direct subscriber charges less returned charges, including cancellations: See instructions.
1
00
Subscriber charges received from:
2 The State of Connecticut to provide health care coverage for state employees, retirees, or their dependents
2
00
3 The State of Connecticut to provide health care coverage for retired teachers, their spouses, or their surviving
spouses covered by plans offered by the State Teachers’ Retirement System
3
00
4 Connecticut municipalities to provide health coverage for their employees and dependents
4
00
5 Nonprofi t organizations or community action agencies to provide health coverage for their employees and
5
dependents
00
6 The federal government to provide coverage for Medicare patients
6
00
7 The State of Connecticut to provide health care coverage for Medicaid recipients
7
00
8 The State of Connecticut to provide health care coverage for eligible benefi ciaries under the HUSKY Plan,
Part A; HUSKY Plan, Part B; or the HUSKY Plus programs
8
00
9 The State of Connecticut to provide health care coverage for recipients of state administered general assistance
9
00
10 The federal Employees Health Benefi ts Fund to provide coverage for qualifi ed enrollees
10
00
11 Individuals eligible for a health coverage tax credit and individuals eligible for a retirement benefi t from the
Connecticut municipal employees’ retirement system and their dependents
11
00
12 Total deductions: Add Lines 2 through 11.
12
00
13 Subtract Line 12 from Line 1.
13
00
14 Health care center tax: Multiply Line 13 by 1.75% (.0175)
14
00
.
15a General business tax credits: See instructions.
15a
00
15b Multiply Line 14 by 70% (.70).
15b
00
15c Enter Line 15a or Line 15b, whichever is less.
15c
00
16 Net tax: Subtract Line 15c from Line 14. If less than zero, enter zero “0.”
16
00
17 Enter prior year overpayment(s).
17
00
18 Payments made with estimated tax payment coupons Form 207 HCC ESA, ESB, ESC, and ESD.
18
00
19 Payments made with extension request Form 207/207 HCC EXT.
19
00
20 Total prior payments: Add Lines 17, 18, and 19.
20
00
21 If Line 20 is greater than Line 16, enter amount overpaid.
21
00
(22a) $_________________ refunded
22 Amount to be: credited to 2011 estimated tax
(22b) $_______________ 22
00
23 If Line 16 is greater than Line 20, enter amount owed.
23
00
24 If late: penalty
(24a) $ __________________ plus interest
(24b) $ ___________________ See instructions.
24
00
25 Interest on underpayment of estimated tax: Attach Form 207I. See instructions.
25
00
26 Balance due with this return. Make check payable to Commissioner of Revenue Services.
26
00
Visit the Department of Revenue Services (DRS) website at to pay electronically.
Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best of my
knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document to DRS is a fi ne of not more than
$5,000, imprisonment for not more than fi ve years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the
preparer has any knowledge.
Signature of principal offi cer
Title
Date
Sign Here
Print name of principal offi cer
Telephone number
Keep a copy
(
)
of this return
Paid preparer’s signature
Date
Preparer’s SSN or PTIN
for your
records.
Firm name and address
FEIN
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